Healthcare Provider Details

I. General information

NPI: 1962791483
Provider Name (Legal Business Name): HOMETOWN DRUG COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 N BROADWAY ST
POTEAU OK
74953-3355
US

IV. Provider business mailing address

PO BOX 459
POTEAU OK
74953-0459
US

V. Phone/Fax

Practice location:
  • Phone: 918-647-2349
  • Fax: 918-647-2359
Mailing address:
  • Phone: 918-647-2349
  • Fax: 918-647-2359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number195660
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JASON CARTER
Title or Position: CEO, OWNER
Credential: PHARMD
Phone: 405-388-4822